Understanding trends and variation in paediatric fracture management in England

Sarah Lucas, Patrick Aldridge & Andrew Hood

07 May 2025

Rationale

GIRFT report found some trusts were manipulating more displaced forearm fractures in the emergency department rather than in theatre. If more trusts adopted this, more conservative, approach to fracture management a significant amount of theatre time could be saved¹.

Many uncomplicated paediatric clavicle fractures can be managed without x-rays², and this is also considered true for toe fractures.

British Society for Children’s Orthopaedic Surgery (BSCOS) guidance suggests that no referral/follow up is required for many fractures of the clavicle, elbow, wrist and toes where there is no or minimal displacement³.

So, there is interest in understanding what the potential reductions in activity could be if trusts were to implement more conservative management of paediatric fractures.

Paediatric Trauma and Orthopaedic Surgery. GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/girft-reports/
Lirette MP et al. (2018) Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study. BMJ Paediatr Open. 10;2(1):e000304.
Modifiable Templates for Management of Common Fractures. https://www.bscos.org.uk/public/resources.

Aims

Calculate the incidence of fractures recorded in emergency care in England, specifically:
- forearm
- elbow
- clavicle
- tibia/fibula
- toe
Understand the trends in fracture management over time.
Investigate the variation in management of these fracture types between trusts, and therefore opportunity for activity savings if there was more widespread conservative management.

Methodology

The study population included those:

- who had attended an emergency department/urgent treatment centre in England between April 2019 and March 2024 AND

- were aged 16 and under AND

- had a SNOMED code for closed fractures of toe, clavicle, elbow, forearm or tibia/fibula recorded

Emergency care dataset (ECDS) linked with records in the Outpatient (OPA) and Admitted Patient Care Episode (APCE) datasets.

The coding of fractures is not sufficiently detailed and reliable to determine specific fracture types, and thus what would be the appropriate treatment at an individual patient level. However, we could calculate the proportion of children with each fracture type that:

had an X-ray in the emergency department
received a follow-up appointment
had a fracture manipulated in theatre (only includes closed manipulations and not re-manipulations)
had a fracture manipulated in the emergency department

Incidence rate and fracture recording

Fracture incidence rates for England (2023/2024)

Forearm fractures are the most common followed by elbow fractures.

Most common fracture types (2023/2024)

SNOMED description		Number	Percentage
Closed fracture of radius (disorder)	Forearm	48,043	35.2
Elbow fracture - closed (disorder)	Elbow	18,613	13.6
Closed fracture of radius AND ulna (disorder)	Forearm	17,498	12.8
Closed fracture of clavicle	Clavicle	15,259	11.2
Closed fracture of phalanx of foot (disorder)	Toe	15,232	11.1
Closed fracture of tibia (disorder)	Tibia/Fibula	8,549	6.3
Closed fracture of ulna (disorder)	Forearm	4,347	3.2
Closed supracondylar fracture of humerus (disorder)	Elbow	3,394	2.5
Closed fracture of fibula (disorder)	Tibia/Fibula	3,278	2.4
Closed fracture of tibia AND fibula (disorder)	Tibia/Fibula	2,145	1.6
Closed Monteggia's fracture (disorder)	Elbow	108	0.1
Closed Galeazzi fracture (disorder)	Forearm	65	0.0
Closed fracture of distal end of radius (disorder)	Forearm	23	0.0

Only showing those fracture types recorded 10 or more times

The majority of fractures are recorded under just a few snomed codes.

‘Closed fracture of radius (disorder)’ will likely include some proximal radius fractures that would be more accurately classified at elbow fractures.

Fractures of great toe were excluded, as these should be followed up. However these codes are not really used, suggesting great toe fractures may be coded as ‘Closed fracture of phalanx of foot (disorder)’ and thus included within our dataset.

Proportion of ED attendances with a fracture code (2022/2023)

Percentage of diagnoses in emergency care that are for our fractures of interest in those aged 16.

Percentage of emergency care attendances without a diagnosis code for those aged 16 or under.

There is considerable variability between providers in the percentage emergency care attendances where a fracture is recorded, even when accounting for the different rates of recording diagnoses seen between trusts.

These differences could be due to:

Alternative provision locally, e.g. in some areas there is independent urgent care provision available.
Regional differences in fracture rate, which may be related to levels of physical activity, visitors from out of area and the demographic of the area.
Fracture diagnoses being disproportionately recorded by trusts.

Incidence rates per 100,000 by ICB (2023/2024)

ICB	Clavicle	Elbow	Forearm	Tibia/Fibula	Toe	Total	% of ED attendances w/o diagnosis
NHS Cornwall and the Isles of Scilly ICB	220	365	1,136	177	262	2,159	1
NHS Herefordshire and Worcestershire ICB	201	308	1,016	142	269	1,934	22
NHS Shropshire, Telford and Wrekin ICB	215	292	971	139	230	1,847	24
NHS Gloucestershire ICB	222	186	1,004	183	205	1,800	37
NHS Derby and Derbyshire ICB	185	256	905	169	232	1,747	13
NHS Somerset ICB	195	280	925	150	190	1,740	18
NHS Dorset ICB	188	280	857	145	194	1,664	26
NHS South Yorkshire ICB	192	305	803	169	193	1,662	18
NHS Norfolk and Waveney ICB	198	281	842	167	165	1,653	8
NHS Devon ICB	188	262	871	163	150	1,634	23
NHS Black Country ICB	164	304	818	148	144	1,578	42
NHS Sussex ICB	162	241	825	128	171	1,528	16
NHS North East and North Cumbria ICB	146	232	748	148	186	1,460	26
NHS Humber and North Yorkshire ICB	187	213	727	136	162	1,425	18
NHS Lincolnshire ICB	146	214	736	134	187	1,417	6
NHS Coventry and Warwickshire ICB	174	189	717	146	149	1,375	16
NHS Bedfordshire, Luton and Milton Keynes ICB	132	246	688	110	146	1,322	22
NHS Greater Manchester ICB	140	196	708	114	164	1,322	32
NHS Mid and South Essex ICB	138	215	660	163	137	1,312	6
NHS Cheshire and Merseyside ICB	150	221	661	139	141	1,311	31
NHS Hampshire and Isle of Wight ICB	134	231	638	139	125	1,267	19
NHS West Yorkshire ICB	156	200	621	132	133	1,243	23
NHS Birmingham and Solihull ICB	127	236	603	123	142	1,232	18
NHS Bristol, North Somerset and South Gloucestershire ICB	125	226	589	177	91	1,208	7
NHS Nottingham and Nottinghamshire ICB	131	216	597	150	114	1,208	13
NHS Northamptonshire ICB	144	202	578	97	118	1,139	13
NHS Bath and North East Somerset, Swindon and Wiltshire ICB	145	191	571	116	94	1,117	24
NHS South West London ICB	130	111	569	149	141	1,101	39
NHS Cambridgeshire and Peterborough ICB	146	179	550	99	120	1,094	45
NHS Suffolk and North East Essex ICB	145	157	523	106	129	1,060	27
NHS Lancashire and South Cumbria ICB	122	170	530	124	107	1,052	31
NHS Hertfordshire and West Essex ICB	110	150	506	100	113	980	22
NHS Surrey Heartlands ICB	130	162	460	102	115	970	31
NHS Leicester, Leicestershire and Rutland ICB	99	168	446	128	94	934	2
NHS Staffordshire and Stoke-on-Trent ICB	87	121	503	88	125	923	12
NHS North Central London ICB	92	135	438	107	92	864	34
NHS Kent and Medway ICB	85	104	440	63	109	801	48
NHS North West London ICB	82	132	393	88	74	770	38
NHS Buckinghamshire, Oxfordshire and Berkshire West ICB	84	116	356	78	55	689	39
NHS Frimley ICB	70	118	327	77	46	639	35
NHS South East London ICB	62	103	293	72	69	598	23
NHS North East London ICB	59	121	276	80	47	584	33

Incidence rates appear to vary by ICB area, but lower rates in some area may be the result of some trusts in those areas not reliably recording diagnoses codes for emergency care attendances.

Trends in and factors influencing paediatric fracture management

Trends in fracture follow-up appointments

Trend towards a reduction in the number upper limb fractures where a follow-up appointment is given.

As a result of the COVID-19 pandemic the proportion of follow up appointments conducted face-to-face has fallen significantly.

Factors influencing whether a follow-up appointment is given

	Odds Ratio	Confidence Intervals	P value

(Intercept)	2.20	2.15 to 2.25	<0.001*
Sex
Female	1.00		Reference
Male	1.12	1.11 to 1.13	<0.001*
Age
5-10 yrs	1.00		Reference
0-4 yrs	0.96	0.94 to 0.97	<0.001*
11-16 yrs	1.15	1.13 to 1.16	<0.001*
Ethnicity
White	1.00		Reference
Asian or Asian British	1.05	1.03 to 1.08	<0.001*
Black or Black British	1.14	1.1 to 1.19	<0.001*
Mixed	1.01	0.98 to 1.05	0.34
Other Ethnic Groups	1.00	0.97 to 1.04	0.86
Missing/Unknown	0.97	0.95 to 0.98	<0.001*
IMD Quintiles
1- Most deprived	1.00		Reference
2	1.08	1.07 to 1.1	<0.001*
3	1.03	1.01 to 1.04	<0.001*
4	1.05	1.04 to 1.07	<0.001*
5- Least deprived	1.08	1.06 to 1.1	<0.001*
Department type
Major Emergency Department	1.00		Reference
Urgent Treatment Centre/Walk in centre	0.96	0.95 to 0.98	<0.001*
Day of the week
Week	1.00		Reference
Weekend	1.06	1.05 to 1.08	<0.001*
Time of day
Day 7am-7pm	1.00		Reference
Night 7pm to 7am	1.12	1.1 to 1.13	<0.001*
Time of year
Autumn	1.00		Reference
Winter	0.94	0.93 to 0.96	<0.001*
Spring	0.95	0.94 to 0.97	<0.001*
Summer	0.99	0.97 to 1	0.06
Year
2019/20	1.00		Reference
2020/21	0.85	0.83 to 0.86	<0.001*
2021/22	0.79	0.77 to 0.8	<0.001*
2022/23	0.72	0.71 to 0.73	<0.001*
2023/24	0.72	0.71 to 0.73	<0.001*
Fracture type
Clavicle	0.79	0.78 to 0.8	<0.001*
Forearm	1.00		Reference
Elbow	2.47	2.43 to 2.52	<0.001*
Tibia/Fibula	2.09	2.05 to 2.14	<0.001*
Toe	0.37	0.36 to 0.37	<0.001*

Children are more likely to be given a follow-up appointment if they are

male
11-16 yrs old
from an asian or black background
living in a less deprived area

They are also more likely to have a follow-up appointment if they attended

an emergency department
on a weekend
at nighttime

Those attending in more recent years were less likely to have a follow-up appointment, further indicating there has been a move towards fewer follow-up appointments.

Trends in fractures manipulated in the ED vs theatre

Manipulation in ED

Manipulation in theatre

The proportion of forearm fractures manipulated in the emergency department has increased and the proportion manipulated in theatre has decreased.

Proportion of fractures manipulated in ED vs theatre

For forearm fractures currently over half of all manipulations are performed in the emergency department.

The total number of manipulations for forearm fractures has reduced.

Factors influencing manipulation of forearm fractures in theatre

	Odds Ratio	Confidence Intervals	P value

(Intercept)	5.87	5.29 to 6.52	<0.001*
Sex
Female	1.00		Reference
Male	0.93	0.88 to 0.99	0.01*
Age
5-10 yrs	1.00		Reference
0-4 yrs	1.62	1.48 to 1.77	<0.001*
11-16 yrs	0.51	0.48 to 0.54	<0.001*
Ethnicity
White	1.00		Reference
Asian or Asian British	0.81	0.73 to 0.91	<0.001*
Black or Black British	0.49	0.41 to 0.59	<0.001*
Mixed	0.69	0.6 to 0.8	<0.001*
Other Ethnic Groups	0.54	0.46 to 0.62	<0.001*
Missing/Unknown	0.85	0.78 to 0.93	<0.001*
IMD Quintiles
1- Most deprived	1.00		Reference
2	0.76	0.7 to 0.82	<0.001*
3	0.71	0.66 to 0.77	<0.001*
4	0.68	0.63 to 0.74	<0.001*
5- Least deprived	0.62	0.57 to 0.67	<0.001*
Department type
Major Emergency Department	1.00		Reference
Urgent Treatment Centre/Walk in centre	5.12	4.58 to 5.74	<0.001*
Day of the week
Week	1.00		Reference
Weekend	1.09	1.03 to 1.15	<0.001*
Time of day
Day 7am-7pm	1.00		Reference
Night 7pm to 7am	1.12	1.04 to 1.2	<0.001*
Time of year
Autumn	1.00		Reference
Winter	0.87	0.8 to 0.95	<0.001*
Spring	1.06	0.99 to 1.14	0.09
Summer	1.17	1.09 to 1.25	<0.001*
Year
2019/20	1.00		Reference
2020/21	0.43	0.4 to 0.47	<0.001*
2021/22	0.41	0.38 to 0.45	<0.001*
2022/23	0.28	0.26 to 0.3	<0.001*
2023/24	0.20	0.18 to 0.22	<0.001*

Children are more likely to have a fracture manipulated in theatre if they are

female
under the age of 5
white
living in a more deprived area

They are also more likely to have a manipulation in theatre if they attended

an urgent treatment centre
on a weekend
at nighttime
in the summer

Those attending in more recent years were less likely to have their fracture manipulated in theatre, further indicating there has been a move towards manipulating more fractures in the emergency department.

Summary of management of fractures

Over the last 5 years

No change in the proportion of fractures being x-rayed.
Slight reduction in the proportion of fractures being followed up, but significant increase in the proportion that are conducted virtually.
The proportion of forearm fractures manipulated in theatre has decreased while the proportion manipulated in the emergency department has increased.
The overall manipulation rate for forearm fractures has reduced over the last 5 years.

Overall, there is a trend towards more conservative management of paediatric fractures.

Opportunities to reduce hospital activity

X-rays for Clavicle and Toes fractures by trust (2022/23)

Percentage of clavicle fractures x-rayed

Min	5.9 %
1st quartile	87.7 %
Median	93.2 %
3rd quartile	95.7 %
Max	100 %

Reducing the percentage of x-rays to the level of the lowest decile of trusts (77.3%) would give an annual reduction in England of 1,986 (15.5%) x-rays.

Percentage of toe fractures x-rayed

Min	2.4 %
1st quartile	72.6 %
Median	82.4 %
3rd quartile	89.7 %
Max	100 %

Reducing the percentage of x-rays to the level of the lowest decile of trusts (62.3%) there would give an annual reduction in England of 2,412 (22.5%) x-rays.

Upper limb fractures with follow-up by trust (2022/23)

Min	19.8 %
1st quartile	56.2 %
Median	65.1 %
3rd quartile	77.2 %
Max	98 %

Reducing the percentage of follow-ups to the level of the lowest decile of trusts (46%) would give an annual reduction in England of 13,768 (30.7%) follow-up appointments.

Min	25.9 %
1st quartile	74.2 %
Median	83.6 %
3rd quartile	90.4 %
Max	100 %

Reducing the percentage of follow-ups to the level of the lowest decile of trusts (61.8%) would give an annual reduction in England of 4,486 (25.8%) follow-up appointments.

Min	5.6 %
1st quartile	46.5 %
Median	61.2 %
3rd quartile	82.2 %
Max	97.4 %

Reducing the percentage of follow-ups to the level of the lowest decile of trusts (31.4%) would give an annual reduction in England of 4,440 (49.9%) follow-up appointments.

Lower limb fractures with follow-up by trust (2022/23)

Min	20.2 %
1st quartile	72.8 %
Median	83.7 %
3rd quartile	90.1 %
Max	100 %

Reducing the percentage of follow-ups to the level of the lowest decile of trusts (60%) would give an annual reduction in England of 2,817 (26.4%) follow-up appointments.

Min	11.1 %
1st quartile	31.7 %
Median	45.4 %
3rd quartile	56.9 %
Max	100 %

Reduced the percentage of follow-ups to the level of the lowest decile of trusts (21.3%) would give an annual reduction in England of 3,260 (53%) follow-up appointments.

Total annual reduction of 28,771 follow-up appointments in England.

This may be an underestimation as number of children may have more than one follow-up appointment that could be deemed unnecessary.

Number of clavicle fracture follow-ups by trust (2022/2023)

This includes all outpatient attendances, including physiotherapy appointments, in the 3 months post-fracture.

There is significant variability between trusts in the number of follow-up appointments for clavicle fractures.

Many clavicle fractures should not require follow-up yet some trusts are averaging 2-3 follow-up appointments per clavicle fracture, indicating a potential to further decrease follow-up appointments if second and subsequent appointments are considered.

Manipulation in theatre by trust (2022/23)

Min	0.2 %
1st quartile	2.3 %
Median	4.4 %
3rd quartile	6.5 %
Max	21.4 %

There could be an annual reduction in England of 1,747 (54.5 %) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (2.3%).

NOTE: Very low numbers at many providers

Min	0 %
1st quartile	0.5 %
Median	1.3 %
3rd quartile	2 %
Max	8.8 %

There could be an annual reduction in England of 177 (67%) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (0.5%).

Summary of the potential activity reductions

	Clavicle	Elbow	Forearm	Tibia/Fibula	Toe	Total
Reduction in x-rays in emergency care	1,986 (15.5%)	-	-	-	2,412 (22.5%)	4,398 (18.7%)
Reduction in follow-up appts	4,440 (49.9%)	4,486 (25.8%)	13,768 (30.7%)	2,817 (26.4%)	3,260 (53%)	28,771 (32.7%)
Reduction in manipulations in theatre	-	177 (67%)	1,747 (54.5%)	-	-	1,924 (55.4%)

Scope to reduce x-rays for clavicle and toe fractures in England by almost a fifth.
Scope to reduce follow-up appointments for elbow, forearm, clavicle, tibia/fibula and toes fractures in England by a third.
While nationally manipulations in theatre have decreased in recent years, at some trusts there is still scope to reduce the proportion of forearm and elbow fractures manipulated in theatre. This could further half the number of elbow and forearm manipulations performed in theatre in England.

Differences between our approach and the GIRFT metric

There are some significant differences between the data included by GIRFT/Model Hospital and the data used in this study. Our analysis:

excluded certain fracture types, e.g open fractures which are assumed to all require treatment in theatre.
excluded any activity coded as re-manipulations.
used only the most recent year where follow-up data is available (2022/23)
links emergency care data to inpatient data and so we are only considering manipulations in theatre for patients identified in the emergency care dataset as having a fracture.

GIRFT metric does not account for any regional differences in fractures rates, but it is unaffected by the poor recording of diagnoses codes in emergency care.

Our measure accounts for regional differences, but does rely on the assumption that the fractures requiring interventions and those that do not are equally likely have a diagnosis code recorded in emergency care.

Comparing methods for calculating the rate of manipulations

Graphs show our data for the number of forearm fractures manipulated in theatre in 2022/2023 (identified by linking to emergency care fracture records), but use different denominators to calculate the rate.

Top figure shows the 20 trusts with the highest (red) and 20 trusts with the lowest (green) rates of manipulations in theatre using total A&E attendances as the denominator.

Bottom figure uses the number of A&E attendances for forearm fractures as the denominator, and the same trusts labelled above are shown in their new positions according to this new metric.

Example 1, using total A&E attendances as the denominator The Royal Cornwall Hospitals Trust has the 11th highest rate of forearm manipulation in theatre in England. Using the number of forearm fractures as the denominator the manipulation rate moves The Royal Cornwall Hospitals Trust out of the highest quartile down to 43rd highest.

Example 2, using total A&E attendances as the denominator Chelsea and Westminster Hospital NHS Foundation trust has the 16th lowest rate in England. However, when the number of forearm fractures is used as the denominator the trust doesn’t actually perform as well as first thought, moving to the 42nd highest, with a similar rate to The Royal Cornwall Hospitals Trust.

Limitations

It is possible some of our numbers may be underestimates due to some issues with coding/reporting especially as diagnoses codes are not always recorded in the emergency care dataset. For example the number of manipulations of elbow fractures in theatre is considered low, this may be a coding issue or related to the inability from the coding to determine which radial fractures should be classed as elbow rather than forearm fractures.
Our incidence rates are for closed fractures only, open fractures, pathological fractures and birth trauma fractures were excluded.
Coding of fractures is not specific enough to determine at an individual level which fractures could be managed more conservatively, so we are relying on comparing proportion between trusts. Some fractures will be more complex and require manipulation and follow-up, but we can’t be sure whether all trusts have a similar proportion of more complex fractures.
Only closed manipulations without internal fixation are included in our data, so if some trusts are treating a higher proportion of fractures with internal fixation then their rate of closed manipulations could appear lower. We have also not included re-manipulations in our data.
There will be a small number of cases where a child has more than one fracture or other injuries.
It should be noted is that data is allocated to the trust where the child attended the emergency department, but where they were followed-up if that is different